Eye pressure
32. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
33. Dr L has raised concerns following her mother’s ophthalmology appointment in June 2022, her eye pressure was high but the Trust did not amend her treatment.
34. We understand how worrying this was for Dr L.
35. The Trust has said, ‘We are sorry that you are unhappy with the information provided in relation to the deterioration of your mother’s vision. Your mother’s ophthalmic medical records have been reviewed further and regrettably we are unable to identify any additional information that we can provide you on these points.’
36. Mrs L had two appointments with her ophthalmologist in June 2022. The first was on 14 June 2022 and her right eye pressure was measured as 34mmHg. On 30 June 2022, Mrs L’s right eye pressure was 18mmHG.
37. Following the results on 14 June, the Trust restarted Mrs L on eye drops and advised it would review her in a months’ time.
38. The NICE guidance says a patient should be reviewed in one to two months if the eye pressure is not controlled and progression may be occurring.
39. We consider the Trust acted appropriately by arranging to review Mrs L again.
40. We consider there is no indication of a failing here. During her first appointment in June 2022 her eye pressure was slightly higher. The Trust therefore prescribed eye drops and during Mrs L’s 30 June review by an ophthalmologist at the Trust her eye pressure had dropped showing the eye drops were working.
41. We understand Mrs L’s review by an ophthalmologist on 30 June was not a pre-arranged review appointment following her appointment on 14 June. This was due to Mrs L’s eye injury but during this appointment, the Trust did check Mrs L’s eye pressure.
42. We hope this goes some way in reassuring Dr L the Trust acted appropriately based on her mother’s eye pressure readings and the eye drops prescribed helped to reduce her eye pressure.
Dentures
43. Dr L has raised concerns her mother’s dentures were thrown away during her admittance in October 2022.
44. We are sorry to hear about this experience and understand the impact this had on her mother.
45. Despite Dr L raising this with the Trust on two occasions, the Trust did not make any findings on this element of her complaint.
46. Mrs L’s records show on 21 October 2022 she raised concerns to the Trust that her dentures were missing. On 31 October 2022, we understand Dr L informed the Trust she thinks her mother ‘put them in a tissue and then they may have been thrown away with the rubbish’.
47. Our nursing adviser says dentures are generally removed before bed and stored at the patient’s bedside. If a patient removes their dentures at any point in the day it would be their responsibility to make sure they are safe or let a member of staff know so that they can store the dentures safely. There is no guidance on this, but staff cannot be aware dentures have been removed unless they have been informed.
48. Overall, we do not consider there is any indication of a failing here. Unfortunately, the Trust were not made aware Mrs L had placed her dentures in a tissue and potentially these may have been mistaken for rubbish and thrown away. We consider this was likely a mistake as the staff had not been made aware of where Mrs L was keeping her dentures.
49. We understand this is not the answer Dr L was expecting but we hope it offers some explanation as to what may have happened with her mother’s dentures.
Physiotherapy
50. Dr L has raised concerns when her mother was discharged she was not prioritised for physiotherapy.
51. We are sorry to hear Dr L understood her mother would be prioritised once she was discharged for physiotherapy. We understand how worrying this would have been when she found out her mother would not be prioritised for these sessions.
52. We understand Dr L says the Trust did not prioritise her mother for community physiotherapy as she was not at a risk of falls even though she had a fall at home, some weeks later.
53. In July 2022, the Trust discharged Mrs L to a care home and there is no mention of community physiotherapy within her medical records.
54. However, our physician adviser says the physiotherapy records may be kept on a different system and therefore the Trust may not have sent these to us.
55. Without these records, we are unable to fully answer whether there is any indication of a failing here. Therefore, we have considered whether we can link the claimed impact, and if we can and if this remains unremedied, before we decide whether we need to request further documents.
56. Mrs L has said due to her mother not being prioritised for community physiotherapy she fell at home and had to return to hospital. We realise this was traumatic for them both.
57. Unfortunately, falls can happen to anyone at any time, even if the person is at low risk of falls or are having physiotherapy. If we were to gather further records and evidence from the Trust, we would never be able to say physiotherapy would have prevented Mrs L from having this fall at home. We appreciate this will be disappointing to Dr L. We hope she understands our thinking on this issue.
58. As we cannot link any potential failing in providing physiotherapy to the fall Mrs L sadly had, we consider there is nothing further we can add here.
Pleural effusion
59. Dr L has raised concerns the Trust noted her mother had a small pleural effusion on a CT scan which was completed in October 2022. However, it did not follow up on this with any referrals or further treatment or monitoring.
60. We would like to thank Dr L for sharing this experience with us. We recognise she was worried her mother had this condition and did not understand why it was not being followed up.
61. The Trust says, ‘it is noted that your mother attended hospital on 9 November 2022 with shortness of breath and confusion. She was admitted to Emergency Management Unit and the working diagnosis was a large left sided pleural effusion and delirium secondary to infection and hyponatraemia (low sodium)’.
62. Mrs L’s medical records say a CT scan conducted at 12.45 on 13 October 2022 showed a small pleural effusion at the bottom of her lung. Our physician adviser says this was not a large pleural effusion.
63. We understand following the CT scan, the Trust discussed the results with a cardiothoracic surgeon from another Trust. Their advice was to discuss with the trauma team. The Trust did this and the trauma team advised conservative management. The trauma team added that no operation or chest drain was needed at this point, but advised to offer analgesia and monitor Mrs L.
64. It is important to note here at this time, Mrs L’s pulse was normal, her oxygen saturation was 98% (good oxygen saturation is understood to be between 94% and 98%), she was not breathless and was coping well.
65. Following the CT scan on 13 October 2022, Mrs L remained in hospital for a further three weeks, until 3 November 2022. Mrs L’s medical records during this time show she was stable, her observations were normal, there was no concerns and she was well at the time of discharge.
66. Our physician adviser says observing Mrs L for three weeks is a considerable amount of time to understand if further treatment would be needed.
67. Our physician adviser also says there is no guidance on what to do if a pleural effusion is seen, but the rib fracture paper says, ‘Follow-up chest radiographs are unnecessary unless indicated by clinical symptoms (eg, new shortness of breath, new or severe pain)’.
68. We consider Mrs L did not have any new or worsening symptoms due to her pleural effusion and therefore further investigation or surgery were not necessary.
69. We understand Mrs L’s pleural effusion has considerably grown in size from when she was discharged on 3 November and when she was readmitted on 10 November. However, we have seen no indication at the time of Mrs L’s discharge on 3 November that her pleural effusion had grown or was causing her problems.
70. Pleural effusions can develop and grow over days or weeks and sometimes can be over hours.
71. We have seen no indication of a failing here. We consider the Trust sought appropriate advice once it diagnosed the pleural effusion and monitored Mrs L for any new symptoms during her three weeks in hospital. We do not consider there is anything further the Trust should have done.
72. We hope our consideration offers Dr L some reassurance with regards to the care her mother received.
Chest drain
73. Dr L has raised concerns when her mother was admitted back to hospital in November 2022 it took the Trust two days to insert a chest drain. We know this was a worrying time for Dr L.
74. The Trust says it discussed the plan for Mrs L’s chest drain with Dr L on 10 November and it inserted the chest drain on 11 November after it had gained consent for the procedure.
75. Mrs L’s medical records show following admittance on 9 November 2022, the Trust carried out another CT scan which showed her pleural effusion had grown and she was suffering from breathlessness. The Trust therefore planned to insert a chest drain.
76. However, Mrs L was being prescribed with clopidogrel (an antiplatelet medication). Our physician adviser says for the Trust to insert the chest drain Mrs L would need to stop taking clopidogrel for several days. This is because clopidogrel thins the blood which can lead to blood loss during the chest drain insertion.
77. This is in line with the BTS guidance which says, ‘clopidogrel....should be stopped 5 days pre-elective procedure’.
78. We can see the Trust discussed this with Dr L who was happy with the plan.
79. Mrs L’s medical records show she was admitted on a Thursday and the chest drain was inserted on the Monday. This is not quite the five days which is quoted in the guidance. However, the Trust assessed Mrs L on Monday which showed she was struggling and very breathless. Therefore, the Trust made the decision to insert the chest drain despite Mrs L not being off clopidogrel for five days.
80. The BTS guidance does go on to say, ‘The operator should consider the risks and benefits of the proposed procedure and the timing of the procedure’. Therefore we consider the Trust acted appropriately.
81. We understand once the chest drain was inserted, after about five hours 1.5 litres of fluid had been drained. Our physician adviser says this shows Mrs L had a very large pleural effusion which needed draining.
82. We consider there is no indication of a failing here. The Trust appropriately delayed the insertion of the chest drain so Mrs L could come of clopidogrel however, due to the size of the pleural effusion and the impact it was having on Mrs L, we consider the Trust made the appropriate decision to insert the chest drain earlier than the five days.
83. We hope this reassures Dr L the Trust acted in line with guidance and inserted the chest drain at an appropriate time.
Eye drops
84. Dr L has raised concerns her mother’s eye drops were not being administered correctly and some that were being prescribed to her were not appropriate with her condition during her admission between 23 June to 31 July.
85. The Trust says, ‘As previously explained in our response, the eye drops your mother required had been prescribed here in Chesterfield. Please accept our apologies for the clear breakdown in communication around your mother’s eye drops’.
86. Mrs L had a diagnosis of chronic narrow angle glaucoma. Mrs L had a prescription for DuoTrav and brinzolamide which she had been using prior to her appointments in June 2022 to lower her eye pressure. Our ophthalmology adviser says both of these drops are appropriate in treating glaucoma.
87. Our ophthalmology adviser says it is not clear why the Trust changed her prescription from brinzolamide to brimonidine but both are suitable to treat glaucoma.
88. We therefore consider Mrs L was receiving the appropriate eye drop treatment for her diagnosis and there is no indication of a failing here.
89. We considered Mrs L’s concerns her mother’s eye drops were not being administered correctly.
90. Mrs L’s medical records show she should have had brinzolamide twice a day and DuoTrav once a day. Mrs L’s medical records show for her stay starting on 23 June to 31 July, the Trust administered these drops in accordance with the prescription instructions. There are some notes that due to Mrs L’s eye injury the Trust would have difficulty in administering her eye drops however, we have seen no evidence of this as the records show the eye drops were given in line with the prescription.
91. We consider the Trust therefore administered Mrs L’s eye drops in line with the prescription. We do not consider there is any evidence of a failing here.
Ophthalmology appointments
92. Dr L has raised concerns during her mother’s time as an inpatient it was very difficult to arrange ophthalmology appointments for her. We appreciate this was frustrating.
93. The Trust has acknowledged there was a delay with the appointments but has said it would not have changed the outcome for Mrs L and her eyesight.
94. When Mrs L was admitted to the hospital on 23 June 2022, she was admitted following a fall in her kitchen which left her with a haematoma (bruising) and swelling around her right eye. We have been unable to find any evidence Mrs L was assessed by an ophthalmologist during this admittance before 30 June 2022 when she was seen by an ophthalmic nurse specialist.
95. Our ophthalmology adviser says as there is an ophthalmology department within the Trust, Mrs L suffers from glaucoma and suffered a blunt injury to her only sighted eye, it would be expected that Mrs L would have been reviewed much sooner than a week after her admittance. They added this would have been particularly important after it was noted her pupil was not reacting appropriately.
96. Our ophthalmology adviser says there is no guidance as to when patient should be seen for an ocular injury but as the injury was to Mrs L’s only sighted eye it should have been done as soon as possible given her physical health.
97. We therefore consider there is an indication of a failing here, in that Mrs L was not seen for seven days by a member of staff from the ophthalmology department at the Trust. We will consider the impact of this next.
98. Dr L feels due to the lack of ophthalmology appointments her mother’s eye sight worsened and deteriorated.
99. Mrs L was not seen by an ophthalmologist until 30 June 2022, seven days after her admission and eye injury.
100. We know on 14 June 2022, Mrs L’s eye pressure was measured as 34mmHg. On 30 June 2022, Mrs L’s right eye pressure was 18mmHG. This shows her eye pressure had reduced. We consider the delay with being seen by an ophthalmologist did not have an immediate impact on her mother’s glaucoma.
101. From Mrs L’s medical records the next instance of Dr L being concerned about her mother’s eyesight is November 2022. We can see following an assessment of Mrs L’s eye sight her eye pressure is measured at 20mmHG, which is a slight increase from 30 June 2022.
102. Glaucoma is a disease which progresses but progression can be slowed with medication. We explained we consider the Trust prescribed Mrs L with appropriate medication.
103. Having considered the impact described, it would be extremely difficult for us to link this slight rise in eye pressure to Mrs L not being seen by an ophthalmologist sooner during her admittance in June 2022.
104. We consider there is nothing further we can add here.
105. Mrs L was much loved and we recognise Dr L made huge sacrifices to care for her mother in the final months of her life. We understand our consideration of her complaint may be difficult to read but we hope in time it offers her some reassurance. We thank Dr L for sharing her experience with us so openly.